Healthcare Fraud Detection

Fraudulent healthcare claims increase the burden to society.
Therefore healthcare fraud detection is now becoming more and more important.
Generally, healthcare frauds are not obvious and thus difficult to detect.
The followings are typical examples of healthcare fraud techniques used by
health care providers and patients;

Providers billing for services not provided.

Providers administering (more) tests and treatments or providing
equipments that are not medically necessary.

Clustering can discover similar fraud cases!

Clustering can be used to find more fraud cases that are similar to known cases.
The following figure shows CMSR Data Miner neural clustering.
It has 9x9 (=81) cells. Each cell contains providers with "similar" attributes. Round figures are
pie charts. Red portions represent fraudulent cases. Green areas are status-unknown portions. Providers within cells with red portions
might be hidden cases that may need investigation;